Impact of subjective sleep quality on objective measures of neurocognitive dysfunction in patients with major depressive disorder.

Background: Sleep disturbances are prevalent in major depressive disorder (MDD). MDD and sleep disturbances are both linked to cognitive impairments. Studies exploring the mechanisms and impact of sleep disturbances on neurocognitive functioning in depressed patients are lacking and proper assessment and therapeutic interventions for sleep disturbances are not part of clinical management of MDD. Aim: We investigated the association between subjective sleep quality and neurocognitive dysfunction in patients with MDD. Materials and Methods: Patients with moderate MDD episode were matched and assigned to two groups with poor and good sleep quality. We used Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality. To measure frontotemporally mediated cognitive functioning, following tests were administered: Wisconsin Card Sorting Test (WCST) and degraded continuous performance test (CPT-DS). Two-tailed independent samples t tests or Mann-Whitney U tests and Pearson's correlation coefficient were performed for the statistical analysis of sleep latency, sleep duration, overall sleep quality, CPT d' value, WCST correct answers, errors, and perseverative errors. Results: Participants with MDD and poor sleep quality performed worse on cognitive tests compared to patients with MDD and good sleep quality. Scores of subjective sleep on PSQI positively correlated with WCST errors (r (60) =0.8883 P = .001) and negatively correlated with WCST correct answers (r (60) = -.869 P = .001) and measures of CPT-DS d' value (r (60) = -.9355 P = .001). Conclusions: Poor sleep quality, notably sleep duration and sleep latency, worsens the neurocognitive impairments of MDD patients. As these impairments are found to be associated with treatment outcomes, sleep disturbances should be additionally assessed and treated in MDD episode.

Clinician treatment choices for post-traumatic stress disorder: ambassadors survey of psychiatrists in 39 European countries.

BACKGROUND: Considering the recently growing number of potentially traumatic events in Europe, the European Psychiatric Association undertook a study to investigate clinicians' treatment choices for post-traumatic stress disorder (PTSD). METHODS: The case-based analysis included 611 participants, who correctly classified the vignette as a case of PTSD, from Central/ Eastern Europe (CEE) (n = 279), Southern Europe (SE) (n = 92), Northern Europe (NE) (n = 92), and Western Europe (WE) (N = 148). RESULTS: About 82% woulduse antidepressants (sertraline being the most preferred one). Benzodiazepines and antipsychotics were significantly more frequently recommended by participants from CEE (33 and 4%, respectively), compared to participants from NE (11 and 0%) and SE (9% and 3%). About 52% of clinicians recommended trauma-focused cognitive behavior therapy and 35% psychoeducation, irrespective of their origin. In the latent class analysis, we identified four distinct "profiles" of clinicians. In Class 1 (N = 367), psychiatrists would less often recommend any antidepressants. In Class 2 (N = 51), clinicians would recommend trazodone and prolonged exposure therapy. In Class 3 (N = 65), they propose mirtazapine and eye movement desensitization reprocessing therapy. In Class 4 (N = 128), clinicians propose different types of medications and cognitive processing therapy. About 50.1% of participants in each region stated they do not adhere to recognized treatment guidelines. CONCLUSIONS: Clinicians' decisions for PTSD are broadly similar among European psychiatrists, but regional differences suggest the need for more dialogue and education to harmonize practice across Europe and promote the use of guidelines.

Ethical dilemmas in contemporary psychiatry: Findings from a survey of National Psychiatric Associations in Europe.

BACKGROUND: The European Psychiatric Association (EPA) is an organization that speaks on behalf of its individual members and members of National Psychiatric Associations (NPAs). The aim of this study to identify and investigate current contents of ethical codes and practices in the countries belonging to EPA. METHODS: The study is an expert survey sent out to 44 representatives of 30 NPAs covering the following topics: the existence of national bodies dealing with ethical issues in psychiatry, the availability of documents relevant to ethical issues, the types of ethical issues addressed at the national level, and the current and envisaged ethical debates. RESULTS: Out of 44 experts invited to participate in the study, 31 NPAs from 30 countries responded (response rate 70.45%). In the majority of countries, the general mission statement serves as the main document covering ethical issues in psychiatry. Most frequently, internal documents were reported to address medical malpractice, workplace bullying, plagiarism, academic fraud, sexual abuse, and discrimination/racism. Furthermore, internal documents cover the ethical assessment of potentially controversial procedures, including psychosurgery, euthanasia, and pregnancy termination. The most important topics for debate at the level of NPAs/EPA were associated with violations of clinical practice standards and human rights. CONCLUSIONS: NPAs are active in the field of professional ethics, defining ethical standards related to interactions among professionals and services provided by mental health care professionals. Future collaboration of NPAs, under the umbrella of the EPA, could allow to develop a database of local ethical documents that would be translated into English and accessible to all EPA members.

An expert review of clozapine in Eastern European countries: Use, regulations and pharmacovigilance.

OBJECTIVES: To compare the prevalence, regulations, and pharmacovigilance practices of clozapine use in Eastern European countries (except Russia). METHODS: Questionnaires and data from administrative databases (2016 and 2021), package inserts and national guidelines were collected from 21 co-authors from 21 countries. Reports of clozapine adverse drug reactions (ADRs) sent to the global pharmacovigilance database (VigiBase™) were analyzed from introduction to December 31, 2022. RESULTS: Clozapine prescription among antipsychotics in 2021 varied six-fold across countries, from 2.8 % in the Czech Republic to 15.8 % in Montenegro. The utilization of antipsychotics in both 2016 and 2021 was highest in Croatia, and lowest in Serbia in 2016, and Montenegro in 2021, which had half the defined daily dose (DDD)/1000/day compared to the Croatian data. From 2016 to 2021, the prevalence of antipsychotic use increased in almost all countries; the proportion of clozapine use mainly remained unchanged. Differences were detected in hematological monitoring requirements and clozapine approved indications. Only a few national schizophrenia guidelines mention clozapine-induced myocarditis or individual titration schemes. The VigiBase search indicated major underreporting regarding clozapine and its fatal outcomes. By comparison, the United Kingdom had less than half the population of these Eastern European countries but reported to VigiBase more clozapine ADRs by 89-fold and clozapine fatal outcomes by almost 300-fold. CONCLUSION: Clozapine is under-utilized in Eastern European countries. Introducing individualized clozapine treatment schedules may help to maximize clozapine benefits and safety. Major improvement is needed in reporting clozapine ADRs and fatal outcomes in Eastern European countries.

The EEG multiverse of schizophrenia.

Research on schizophrenia typically focuses on one paradigm for which clear-cut differences between patients and controls are established. Great efforts are made to understand the underlying genetical, neurophysiological, and cognitive mechanisms, which eventually may explain the clinical outcome. One tacit assumption of these "deep rooting" approaches is that paradigms tap into common and representative aspects of the disorder. Here, we analyzed the resting-state electroencephalogram (EEG) of 121 schizophrenia patients and 75 controls. Using multiple signal processing methods, we extracted 194 EEG features. Sixty-nine out of the 194 EEG features showed a significant difference between patients and controls, indicating that these features detect an important aspect of schizophrenia. Surprisingly, the correlations between these features were very low. We discuss several explanations to our results and propose that complementing "deep" with "shallow" rooting approaches might help in understanding the underlying mechanisms of the disorder.

Visual masking deficits in schizophrenia: a view into the genetics of the disease through an endophenotype.

Schizophrenia is a severe psychiatric disorder determined by a complex mixture of genetic and environmental factors. To better understand the contributions of human genetic variations to schizophrenia, we performed a genome-wide association study (GWAS) of a highly sensitive endophenotype. In this visual masking endophenotype, two vertical bars, slightly shifted in the horizontal direction, are briefly presented (vernier offset). Participants are asked to indicate the offset direction of the bars (either left or right). The bars are followed by a grating mask, which makes the task both spatially and temporally challenging. The inter-stimulus interval (ISI) between the vernier and the mask was determined in 206 patients with schizophrenia, 109 first-order relatives, and 143 controls. Usually, in GWAS studies, patients are compared to controls (i.e., a binary task) without considering the large differences in performance between patients and controls, as it occurs in many paradigms. The masking task allows for a particularly powerful analysis because the differences in ISI within the patient population are large. We genotyped all participants and searched for associations between human polymorphisms and the masking endophenotype using a linear mixed model. We did not identify any genome-wide significant associations (p < 5 × 10-8), indicating that common variants with strong effects are unlikely to contribute to the large inter-group differences in visual masking. However, we found significant differences in polygenetic risk scores (PRS) between patients and controls, and relatives and controls.

Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries.

BACKGROUND: While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe. METHODS: We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style - Staff questionnaire and a set of questions regarding clinicians' expertise, training, and practice. RESULTS: SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style. CONCLUSIONS: The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.

Intact and deficient contextual processing in schizophrenia patients.

Schizophrenia patients are known to have deficits in contextual vision. However, results are often very mixed. In some paradigms, patients do not take the context into account and, hence, perform more veridically than healthy controls. In other paradigms, context deteriorates performance much more strongly in patients compared to healthy controls. These mixed results may be explained by differences in the paradigms as well as by small or biased samples, given the large heterogeneity of patients' deficits. Here, we show that mixed results may also come from idiosyncrasies of the stimuli used because in variants of the same visual paradigm, tested with the same participants, we found intact and deficient processing.

Mental health services in Scandinavia and Eurasia: comparison of financing and provision.

The aim of this study was to compare financial and human resources for mental health services in selected Scandinavian and Eurasian countries. A cross-sectional descriptive and analytical approach was adopted to analyse questionnaire data provided by members of the Ukraine-Norway-Armenia Partnership Project. We compared Scandinavia (Sweden and Norway) and Eurasia (Armenia, Georgia, Kyrgyzstan and Ukraine). Health expenditure in Eurasia was generally below 4% of gross domestic product, with the exception of Georgia (10.2%), compared with 11% in Scandinavia. Inpatient hospital care commonly exceeded 50% of the mental health budget. The central governments in Eurasia paid for over 50% of the health expenditure, compared to 2% in Scandinavia. The number of mental health personnel per head of population was much smaller in Eurasia than Scandinavia. Financial and human resources were limited in Eurasia and mainly concentrated on institutional services. Health activities were largely managed by central governments. Community-based mental healthcare was poorly implemented, compared to Scandinavia, especially for children and adolescents.

Embedded figures in schizophrenia: A main deficit but no specificity.

Visual deficits are core deficits of schizophrenia. Classically, deficits are determined with demanding psychophysical tasks requiring fine-grained spatial or temporal resolution. Less is known about holistic processing. Here, we employed the Leuven Embedded Figures Test (L-EFT) measuring classic aspects of Gestalt processing. A target shape is embedded in a context and observers have to detect as quickly as possible in which display the target is embedded. Targets vary in closure, symmetry, complexity, and good continuation. In all conditions, schizophrenia patients had longer RTs compared to controls and depressive patients and to a lesser extent compared to their siblings. There was no interaction suggesting that, once the main deficit of schizophrenia patients is discarded, there are no further deficits in Gestalt perception between the groups. This result is in line with a growing line of research showing that when schizophrenia patients are given sufficient time to accomplish the task, they perform as well as controls.

Mental health services during the first wave of the COVID-19 pandemic in Europe: Results from the EPA Ambassadors Survey and implications for clinical practice.

BACKGROUND: The COVID-19 pandemic caused an unprecedented worldwide crisis affecting several sectors, including health, social care, economy and society at large. The World Health Organisation has emphasized that mental health care should be considered as one of the core sectors within the overall COVID-19 health response. By March 2020, recommendations for the organization of mental health services across Europe have been developed by several national and international mental health professional associations. METHODS: The European Psychiatric Association (EPA) surveyed a large European sample of psychiatrists, namely the "EPA Ambassadors", on their clinical experience of the impact of COVID-19 pandemic on the treatment of psychiatric patients during the month of April 2020 in order to: a) identify and report the views and experiences of European psychiatrists; and b) represent and share these results with mental health policy makers at European level. Based on the recommendations issued by national psychiatric associations and on the results of our survey, we identified important organisational aspects of mental health care during the peak of the first wave of the COVID-19. RESULTS: While most of the recommendations followed the same principles, significant differences between countries emerged in service delivery, mainly relating to referrals to outpatients and for inpatient admission, assessments and treatment for people with mental disorders. Compared to previous months, the mean number of patients treated by psychiatrists in outpatient settings halved in April 2020. In the same period, the number of mentally ill patients tested for, or developing, COVID-19 was low. In most of countries, traditional face-to-face visits were replaced by online remote consultations. CONCLUSIONS: Based on our findings we recommend: 1) to implement professional guidelines into practice and harmonize psychiatric clinical practice across Europe; 2) to monitor the treatment outcomes of patients with COVID-19 and pre-existing mental disorders; 3) to keep psychiatric services active by using all available options (for example telepsychiatry); 4) to increase communication and cooperation between different health care providers.

The Implementation of the WHO Mental Health Gap Intervention Guide (mhGAP-IG) in Ukraine, Armenia, Georgia and Kyrgyz Republic.

Despite the increasing burden of mental disorders, a lot of people worldwide suffer a gap in receiving necessary care in these countries. To close this gap, the WHO has developed mhGAP training modules aimed at scaling up mental health and substance use disorders services, especially in low- and middle-income countries. This article presents the experience of implementing the Mental Health Gap Action Programme (mhGAP) in Ukraine, Armenia, Georgia, and Kyrgyz Republic. Data were gathered from an electronic questionnaire administered to representatives from higher educational institutions where the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) was implemented in existing curricula for medical students, interns, and residents in family medicine and neurology, practicing physicians, and master's program in mental health students. More than 700 students went through the programs that provided the feedback. Evaluations of program effectiveness mainly involved standard discipline tests or pre- and post-tests proposed in the mhGAP trainer manual. This finding suggested that mhGAP-IG can be successfully adapted and implemented both on undergraduate and on postgraduate education levels and among medical and nonmedical specialists. Future evaluations need to more definitively assess the clinical effectiveness of mhGAP-IG implementation.

Electrophysiological correlates of visual backward masking in patients with bipolar disorder.

In visual backward masking (VBM), a target is followed by a mask that decreases target discriminability. Schizophrenia patients (SZ) show strong and reproducible masking impairments, which are associated with reduced EEG amplitudes. Patients with bipolar disorder (BP) show masking deficits, too. Here, we investigated the neural EEG correlates of VBM in BP. 122 SZ, 94 unaffected controls, and 38 BP joined a standard VBM experiment. 123 SZ, 94 unaffected controls and 16 BP joined a corresponding EEG experiment, analyzed in terms of global field power. As in previous studies, SZ and BP show strong masking deficits. Importantly and similarly to SZ, BP show decreased global field power amplitudes at approximately 200 ms after the target onset, compared to controls. These results suggest that VBM deficits are not specific for schizophrenia but for a broader range of functional psychoses. Potentially, both SZ and BP show deficient target enhancement.

Universal Patterns in Color-Emotion Associations Are Further Shaped by Linguistic and Geographic Proximity.

Many of us "see red," "feel blue," or "turn green with envy." Are such color-emotion associations fundamental to our shared cognitive architecture, or are they cultural creations learned through our languages and traditions? To answer these questions, we tested emotional associations of colors in 4,598 participants from 30 nations speaking 22 native languages. Participants associated 20 emotion concepts with 12 color terms. Pattern-similarity analyses revealed universal color-emotion associations (average similarity coefficient r = .88). However, local differences were also apparent. A machine-learning algorithm revealed that nation predicted color-emotion associations above and beyond those observed universally. Similarity was greater when nations were linguistically or geographically close. This study highlights robust universal color-emotion associations, further modulated by linguistic and geographic factors. These results pose further theoretical and empirical questions about the affective properties of color and may inform practice in applied domains, such as well-being and design.

WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG): the first pre-service training study.

BACKGROUND: Despite the increasing burden of mental, neurological, and substance use (MNS) disorders, a significant treatment gap for these disorders continues to exist across the world, and especially in low- and middle-income countries. To bridge the treatment gap, the World Health Organization developed and launched the Mental Health Gap Action Programme (mhGAP) and the mhGAP Intervention Guide (mhGAP-IG) to help train non-specialists to deliver care. Although the mhGAP-IG has been used in more than 100 countries for in-service training, its implementation in pre-service training, that is, training prior to entering caregiver roles, is very limited. AIM OF THE STUDY: The aim of this study was to collect and present information about the global experience of academic institutions that have integrated WHO's mhGAP-IG into pre-service training. METHODS: A descriptive cross-sectional study was conducted using an electronic questionnaire, from December 2018 to June 2019. RESULTS: Altogether, eleven academic institutions across nine countries (Mexico, Nigeria, Liberia, Sierra Leone, Somaliland, Armenia, Georgia, Ukraine and Kyrgyzstan) participated in this study. Five of the institutions have introduced the mhGAP-IG by revising existing curricula, three by developing new training programmes, and three have used both approaches. A lack of financial resources, a lack of support from institutional leadership, and resistance from some faculty members were the main obstacles to introducing this programme. Most of the institutions have used the mhGAP-IG to train medical students, while some have used it to train medical interns and residents (in neurology or family medicine) and nursing students. Use of the mhGAP-IG in pre-service training has led to improved knowledge and skills to manage mental health conditions. A majority of students and teaching instructors were highly satisfied with the mhGAP-IG. CONCLUSIONS: This study, for the first time, has collected evidence about the use of WHO's mhGAP-IG in pre-service training in several countries. It demonstrates that the mhGAP-IG can be successfully implemented to train a future cadre of medical doctors and health nurses.